PFD report

Charles Gavin BRADLEY · Prevention of Future Deaths report

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Issued 17 Mar 2014•Liverpool

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised2

  1. Failure of transfer communications and record-keeping
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Inadequate recording of patient falls
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Unreliable documentation of falls and related clinical response
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of transfer communications and record-keeping

Wider context from the report

“During the investigation and inquest into Mr Bradley’s death it was found that the record-keeping and communications at Arrowe Park Hospital were inadequate, ineffective making them unsafe. This was evidenced by findings that though Leeds Teaching Hospital had effective records as to the arrangements for the transfer of Mr Bradley to Arrowe Park on the 21st February 2013, when Mr Bradley arrived at Arrowe Park they were not expecting him. This is likely to have caused added worry and stress to his rehabilitation plan. It is further evidenced by the inadequate recording of his fall on the 21st February 2013. From the evidence it was unclear as to whether it was witnessed or not, was it in a bathroom and if so why was there mention of a filing cabinet near he lay? In other cases the matters reported could result in fatalities. Documentation, recordkeeping and communications are core basic skills for all who work in healthcare. Neither the HEALTH aspect nor the CARE aspect of a health care service can be delivered without these basic skills. It would be helpful to see a cross Trust action plan with regard to the improving documentation, record-keeping and communication in the response to this report ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate recording of patient falls

Wider context from the report

“During the investigation and inquest into Mr Bradley’s death it was found that the record-keeping and communications at Arrowe Park Hospital were inadequate, ineffective making them unsafe. This was evidenced by findings that though Leeds Teaching Hospital had effective records as to the arrangements for the transfer of Mr Bradley to Arrowe Park on the 21st February 2013, when Mr Bradley arrived at Arrowe Park they were not expecting him. This is likely to have caused added worry and stress to his rehabilitation plan. It is further evidenced by the inadequate recording of his fall on the 21st February 2013. From the evidence it was unclear as to whether it was witnessed or not, was it in a bathroom and if so why was there mention of a filing cabinet near he lay? In other cases the matters reported could result in fatalities. Documentation, recordkeeping and communications are core basic skills for all who work in healthcare. Neither the HEALTH aspect nor the CARE aspect of a health care service can be delivered without these basic skills. It would be helpful to see a cross Trust action plan with regard to the improving documentation, record-keeping and communication in the response to this report ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unreliable documentation of falls and related clinical response.

Open source report
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026